Healthcare Provider Details

I. General information

NPI: 1629224456
Provider Name (Legal Business Name): TARA LEE COSTA-WALLACE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2008
Last Update Date: 08/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 METACOM AVE
BRISTOL RI
02809-5182
US

IV. Provider business mailing address

580 METACOM AVE
BRISTOL RI
02809-5182
US

V. Phone/Fax

Practice location:
  • Phone: 401-253-2723
  • Fax: 401-253-3980
Mailing address:
  • Phone: 401-253-2723
  • Fax: 401-253-3980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH03692
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: